Eqeepo W-8BEN

Certificate of Foreign Status of Beneficial Owner for United States Tax Withholding and Reporting (Individuals)

For use by individuals. Entities must use Form W-8BEN-E. Give this form to the withholding agent or payer. Do not send to the IRS.

Do NOT use this form if:

You are NOT an individual
You are a U.S. citizen or other U.S. person, including a resident alien individual
You are a beneficial owner claiming that income is effectively connected with the conduct of trade or business within the United States (other than personal services)
You are a beneficial owner who is receiving compensation for personal services performed in the United States
You are a person acting as an intermediary

Note: If you are a resident in a FATCA partner jurisdiction, certain tax account information may be provided to your jurisdiction of residence.

Part I Identification of Beneficial Owner

Name & Email of individual who is the beneficial owner

Full Name *

Email Address *

Country of Citizenship *

Permanent residence address

Street Address (including apt. no.) *

Country of Residence *

City or town, state or province. Include postal code where appropriate *

Mailing address (if different from above)

Street Address (including apt. no.)

Country of Residence

City or town, state or province. Include postal code where appropriate

Date of birth (MM-DD-YYYY) *

Part II Certification

Under penalties of perjury, I declare that I have examined the information on this form and to the best of my knowledge and belief it is true, correct, and complete. I further certify under penalties of perjury that:

I am the individual that is the beneficial owner (or am authorized to sign for the individual that is the beneficial owner) of all the income or proceeds to which this form relates;
The person named on line 1 of this form is not a U.S. person;
This form relates to income not effectively connected with the conduct of a trade or business in the United States;

Furthermore, I authorize this form to be provided to any withholding agent that has control, receipt, or custody of the income of which I am the beneficial owner or any withholding agent that can disburse or make payments of the income of which I am the beneficial owner. I agree that I will submit a new form within 30 days if any certification made on this form becomes incorrect.

I certify that I have the capacity to sign for the person identified on line 1 of this form. signature of beneficial owner (or individual authorized to sign for beneficial owner).

I agree to be legally bound by this agreement.